Provider Demographics
NPI:1033246483
Name:PRN PHARMACIES LTD
Entity Type:Organization
Organization Name:PRN PHARMACIES LTD
Other - Org Name:MEDICAP PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:LEDBETTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-252-5349
Mailing Address - Street 1:1101 US HIGHWAY 45 N
Mailing Address - Street 2:PO BOX 449
Mailing Address - City:ELDORADO
Mailing Address - State:IL
Mailing Address - Zip Code:62930-3768
Mailing Address - Country:US
Mailing Address - Phone:618-273-4941
Mailing Address - Fax:618-273-8124
Practice Address - Street 1:1101 US HIGHWAY 45 N
Practice Address - Street 2:
Practice Address - City:ELDORADO
Practice Address - State:IL
Practice Address - Zip Code:62930-3768
Practice Address - Country:US
Practice Address - Phone:618-273-4941
Practice Address - Fax:618-273-8124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL54006692333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL371061340001Medicaid
1440217OtherOTHER ID NUMBER-COMMERCIAL NUMBER
IL3710613406293001OtherHFS PAYEE #
IL3710613406293001OtherHFS PAYEE #
IL=========001Medicaid